Healthcare Provider Details

I. General information

NPI: 1427763754
Provider Name (Legal Business Name): HALEY LYNN RYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 S LEE ST
FORT GIBSON OK
74434-8708
US

IV. Provider business mailing address

799 S LEE ST
FORT GIBSON OK
74434-8708
US

V. Phone/Fax

Practice location:
  • Phone: 918-616-8490
  • Fax:
Mailing address:
  • Phone: 918-616-8490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2462
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: